Transperineal vs Transrectal Prostate Biopsy-The PREVENT Randomized Clinical Trial.

This randomized clinical trial compares the effect of transperineal vs transrectal prostate biopsy on infection rates after biopsy.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients Under Guardianships.

Palliative care clinicians often help facilitate coordination of care, complex serious illness, and end-of-life medical decision-making. However, the clinical and legal issues related to guardianship can complicate the decision-making process, care delivery, outcomes, and the role of the palliative care clinician. Adult patients who have a guardian have been found by a court to be unable to make some or all decisions for themselves. Providing care for patients under guardianship is where medicine overlaps with legal rights. It is crucial to be familiar with the patients' rights and the guardians' responsibilities to clarify medical decision-making processes and identify necessary authorities. This article uses an interprofessional approach to leverage the expertise of physicians, nurses, lawyers, and guardians and to guide palliative care clinicians to optimally support patients under guardianship.

Characterizing patient experiences with repeat artificial urinary sphincter revisions through quantitative surveys and qualitative patient interviews.

Background: Artificial urinary sphincter (AUS) placement remains the gold-standard treatment for post-prostatectomy urinary incontinence (PPUI), despite their need for periodic surgical revision. Objective: To understand the experiences of patients who undergo repeat AUS revisions. Design: Mixed design including quantitative surveys and qualitative interviews for thematic analysis. Methods: Men with ⩾2 revisions were collected from a single-institution, retrospective database of AUS patients. Participants were interviewed about their prostatectomy, incontinence, AUS placement, and revisions. A survey was administered utilizing validated tools (e.g., Decision Regret Scale (DRS), Incontinence Impact Questionnaire-7) for quantitative analysis. Interview transcripts were used for qualitative thematic analysis. Results: Of 26 respondents, 20 completed the interview. Twenty-three men completed the survey. The mean DRS score for prostatectomy was 24 (standard deviation (SD) = 27), indicating low regret. Median Incontinence Impact Questionnaire score was 54 (SD = 27), with 70% of participants describing their PPUI as "severe." Participants experienced a significant decrease in daily pad usage with AUS placement (5.5 pre-AUS vs 1.4 post-AUS, p < 0.0001). Qualitative analysis revealed themes involving prostatectomy urgency, physician-patient relationships, expectation setting, and quality of follow-up. Most participants (96%) were satisfied with their initial AUS placement and endorsed a positive relationship with their urologist. However, 22% of participants were unaware of device limitations, including the need for revision. Some participants (26%) were uncertain of the status of their AUS, while some participants (35%) desired improved follow-up. Conclusions: Initial improvement and positive experiences with urologists motivate patients to undergo AUS repeat revision. Urologists should emphasize the limitations of the AUS before placement and follow up with patients to evaluate their needs for future care.

Narrative patent review of penile clamp, artificial urinary sphincter, and sling innovation in the management of male stress urinary incontinence.

Background and Objective: Stress urinary incontinence (SUI) is the involuntary loss of urine affecting 1-3% of the male population. To manage leakage, patients may try a plethora of penile clamps. and may even consider artificial urinary sphincters (AUS) or sling implantation. We aimed to synthesize the evolution of the modern clamp, AUS, and sling through a comprehensive patent search. Methods: Patents were found through the databases of United States Patent and Trademark Office (USPTO), GooglePatents, and the World Intellectual Property Office Patentscope, covering patents published through January 6, 2024. Key Content and Findings: We found 30 different patents (10 clamps, 13 AUS, and 7 slings), including the patents pertaining to the functionalities and design of five commercially available penile clamps, the American Medical System 800 (AMS 800), the InVance, AdVance, AdVance XP, and Virtue Slings. The clamps, spanning back to 1938 with Bard Cunningham's clamp, have undergone significant refinements. For example, inventors such as Edson S. Outwin and Juan F. V. Wiesner, have modified the location of the primary pressure point. Accessibility has also improved with inventors, such as Gerald French and John W. Timmons, fastening the clamps with Velcro®, as opposed to the screw and ratchet catch closing mechanism, as in Cunningham's clamp. Similarly, the AUS has greatly evolved since Foley's 1947 "Artificial Sphincter and Method", which was the primary AUS precedent to Mark Polyak's AUS invention, which covered the essential elements and functionalities, such as the incorporation of a balloon reservoir, for the AMS 800. In addressing AUS limitations, inventors such as David W. Anderson and Louisa Thomas have created non-hydraulic AUSs. Likewise, the male sling has seen an evolution in the method of securement, from the use of fixed bone anchors in the InVance sling to the transobturator route used in the AdVance XP, avoiding bone complications. Additionally, innovation in sling adjustment of urethral compression allows for adjustable urethral elevation and distal compression respectively. Recent patents have claimed technological integration for clamps, AUS, and slings, especially concerning automation. Conclusions: Overall, patents have built upon the limitations of previous devices. However, there is still a need to innovate for increased clamp comfort and reduced reoperation rates for the AUS and sling.

The Role of the Lead Hip in Collegiate Baseball Pitching: Implications for Ball Velocity and Upper-Extremity Joint Moments.

Hip flexibility is an important biomechanical factor for a baseball pitcher. However, there have been limited investigations into the association between upper-extremity joint stresses and ball velocity and hip flexibility, as assessed via motion patterns during the pitch. The purpose of this study was to provide a detailed kinematic description of the lead hip during the pitch and determine the association between lead hip motion and both ball velocity and the elbow varus moment. This study was a secondary analysis of the kinematic and kinetic data previously collected on 99 collegiate-level baseball pitchers using standard optoelectronic motion capture. Significant associations were noted between lead hip internal rotation and both peak ball velocity and the elbow varus moment. The data indicated that for every 10° increase in internal lead hip rotation, ball velocity increased by 0.6 m/s (P < .001, r2 = .26), and the elbow varus moment increased by 5 N·m (P < .001, r2 = .33). The results of this study suggested that internal hip rotation may be an important means of identifying pitchers that may be at risk for future injury.

Clinical and Behavioral Research at the National Institute on Aging-50 Years of Innovation.

This Viewpoint discusses multicomplexity and dementia, 2 areas of clinical and behavioral research where the National Institute on Aging has made integral and distinctive contributions.

In-Hospital Delirium and Disability and Cognitive Impairment After COVID-19 Hospitalization.

Importance: Older adults who are hospitalized for COVID-19 are at risk of delirium. Little is known about the association of in-hospital delirium with functional and cognitive outcomes among older adults who have survived a COVID-19 hospitalization. Objective: To evaluate the association of delirium with functional disability and cognitive impairment over the 6 months after discharge among older adults hospitalized with COVID-19. Design, Setting, and Participants: This prospective cohort study involved patients aged 60 years or older who were hospitalized with COVID-19 between June 18, 2020, and June 30, 2021, at 5 hospitals in a major tertiary care system in the US. Follow-up occurred through January 11, 2022. Data analysis was performed from December 2022 to February 2024. Exposure: Delirium during the COVID-19 hospitalization was assessed using the Chart-based Delirium Identification Instrument (CHART-DEL) and CHART-DEL-ICU. Main Outcomes and Measures: Primary outcomes were disability in 15 functional activities and the presence of cognitive impairment (defined as Montreal Cognitive Assessment score <22) at 1, 3, and 6 months after hospital discharge. The associations of in-hospital delirium with functional disability and cognitive impairment were evaluated using zero-inflated negative binominal and logistic regression models, respectively, with adjustment for age, month of follow-up, and baseline (before COVID-19) measures of the respective outcome. Results: The cohort included 311 older adults (mean [SD] age, 71.3 [8.5] years; 163 female [52.4%]) who survived COVID-19 hospitalization. In the functional disability sample of 311 participants, 49 participants (15.8%) experienced in-hospital delirium. In the cognition sample of 271 participants, 31 (11.4%) experienced in-hospital delirium. In-hospital delirium was associated with both increased functional disability (rate ratio, 1.32; 95% CI, 1.05-1.66) and increased cognitive impairment (odds ratio, 2.48; 95% CI, 1.38-4.82) over the 6 months after discharge from the COVID-19 hospitalization. Conclusions and Relevance: In this cohort study of 311 hospitalized older adults with COVID-19, in-hospital delirium was associated with increased functional disability and cognitive impairment over the 6 months following discharge. Older survivors of a COVID-19 hospitalization who experience in-hospital delirium should be assessed for disability and cognitive impairment during postdischarge follow-up.

Borderline personality disorder and learning: The influences of emotional state and social versus nonsocial feedback.

BACKGROUND: Borderline personality disorder (BPD) has been associated with decision-making deficits, yet such deficits may be context dependent, particularly emotional state and social context. Reinforcement learning models offer an avenue to pinpoint decision-making impairments. The current study used reinforcement learning models to examine whether feedback type (social vs. nonsocial) or emotional state (neutral vs. negative) influence the association between BPD and decision making. METHOD: Adults (N = 131) with a range of BPD symptoms completed a diagnostic interview and a computerized learning task after neutral and negative emotion inductions. We examined accuracy, learning rate, and exploration. RESULTS: We conducted linear models to examine the association between BPD criteria, feedback type, and emotional state on learning parameters and learning accuracy. We found that the negative emotion condition was associated with greater exploration, particularly for those with elevated BPD features. Furthermore, elevated BPD features were associated with impaired accuracy when aiming to avoid loss. A 3-way interaction between BPD, emotion, and feedback indicated that, for people with higher BPD features, learning performance was further impaired when receiving social feedback in the negative emotion condition. LIMITATIONS: Several limitations warrant mention, including a relatively homogenous sample, possible co-occurring diagnoses, and methodological consideration with the learning task. CONCLUSIONS: The present study underscored the link between BPD and learning impairments. Amplified learning alterations under negative social contexts have important implications for identifying optimal venues to teach new skills (of relevance to treatment) for those with BPD.

Anthropogenic Eutrophication Drives Major Food Web Changes in Mwanza Gulf, Lake Victoria.

Discerning ecosystem change and food web dynamics underlying anthropogenic eutrophication and the introduction of non-native species is necessary for ensuring the long-term sustainability of fisheries and lake biodiversity. Previous studies of eutrophication in Lake Victoria, eastern Africa, have focused on the loss of endemic fish biodiversity over the past several decades, but changes in the plankton communities over this same time remain unclear. To fill this gap, we examined sediment cores from a eutrophic embayment, Mwanza Gulf, to determine the timing and magnitude of changes in the phytoplankton and zooplankton assemblages over the past century. Biogeochemical proxies indicate nutrient enrichment began around ~ 1920 CE and led to rapid increases in primary production, and our analysis of photosynthetic pigments revealed three zones: pre-eutrophication (prior to 1920 CE), onset of eutrophication with increases in all pigments (1920-1990 CE), and sustained eutrophication with cyanobacterial dominance (1990 CE-present). Cladoceran remains indicate an abrupt decline in biomass in ~ 1960 CE, in response to the cumulative effects of eutrophication and lake-level rise, preceding the collapse of haplochromine cichlids in the 1980s. Alona and Chydorus, typically benthic littoral taxa, have remained at relatively low abundances since the 1960s, whereas the abundance of Bosmina, typically a planktonic taxon, increased in the 1990s concurrently with the biomass recovery of haplochromine cichlid fishes. Overall, our results demonstrate substantial changes over the past century in the biomass structure and taxonomic composition of Mwanza Gulf phytoplankton and zooplankton communities, providing a historical food web perspective that can help understand the recent changes and inform future resource management decisions in the Lake Victoria ecosystem. Supplementary Information: The online version contains supplementary material available at 10.1007/s10021-024-00908-x.

Morbidity Associated with Deviation from Pediatric Status Epilepticus Guidelines.

Treatment guidelines for the management of pediatric status epilepticus (PSE) are often institution-specific. We aim to characterize deviation from our hospital-based PSE treatment guidelines, the total dosage of benzodiazepines administered, and the need for intubation. The study population included all patients with an ICD -10 code for PSE who required admission to the Pediatric Intensive Care Unit (PICU) from April 2019 to April 2022. There were 66 PICU admissions. All patients with concern for PSE and altered mental status are admitted to the PICU. The cohort was divided between those treated according to the PSE protocol (benzodiazepine dose (0.05 mg/kg- 0.2 mg/kg) versus those who had low dose (≤0.05 mg/kg) and high-dose benzodiazepine (> 0.2 mg/kg) totals. The dosage was calculated as the total dose of benzodiazepines received pre-hospital and in the ED before intubation or transport. Forty-one (62 %) of patients received high-dose benzodiazepines (median 0.34 mg/kg [IQR 0.29-0.56], 19 (29 %) received recommended-dose benzodiazepines (median 0.13 mg/kg [IQR 0.09,0.15] and 6 (9 %) received low-dose (median 0.05 mg/kg [IQR 0.03,0.05]. The high-dose group was 15.9 (95 % CI = 3.7, 99.9) times more likely to be intubated controlling for the location of care (tertiary versus community hospital), and the age of the patient. The recommended-dose and low-dose groups required intubation with much less frequency.

Early Post-Operative Events After Urethroplasty in Obese Patients: A Multi-Institutional Retrospective Series.

OBJECTIVE: To compare early urethroplasty outcomes in non-obese, obese and morbidly obese patients undergoing urethroplasty for urethral stricture disease. The impact of obesity on outcomes is poorly understood but will be increasingly important as obesity continues to rise. METHODS: Patients underwent urethroplasty at one of the 5 institutions between January 2016 and December 2020. Obese (BMI 30-39.9, n = 72) and morbidly obese (BMI >40, n = 49) patients were compared to normal weight (BMI <25, n = 29) and overweight (BMI 25-29.9, n = 51) patients. Demographics, comorbidities, and stricture characteristics were collected. Outcomes including complications, recurrence, and secondary interventions were compared using univariate and multivariate analysis. RESULTS: Two hundred and one patients (Mean BMI 34.1, Range 18.4-65.2) with mean age 52.2 years (SD=17.2) were analyzed. Median follow-up time was 3.71 months. Obese patients were younger (P = .008), had more anterior (P <.001), iatrogenic and LS-associated strictures (P = .036). Sixty-day complication rate was 26.3% with no differences between cohorts (P = .788). Around 9.5% of patients had extravasation at catheter removal, 18.9% reported stricture recurrence, and 7.4% required additional interventions. Obese patients had greater estimated blood loss (P = .001) and length of stay (P = .001). On multivariate analysis, smoking associated with contrast leak (OR 7.176, 95% CI 1.13-45.5) but not recurrence or need for intervention (P = .155, .927). CONCLUSION: Obese patients in our cohort had more anterior, iatrogenic, and LS-related strictures. However, obesity is not associated with complications, contrast leak, secondary interventions, or recurrence. Obese had higher blood loss and length of stay. Urethroplasty is safe and effective in obese patients.

Personal genital satisfaction is associated with differences in perception of male and female sexual anatomy and function.

BACKGROUND: Prior studies primarily of men correlated low personal genital satisfaction (PGS) with decreased sexual activity; however, the association between PGS and genital anatomy perceptions is unknown, and there is a paucity of studies examining women. AIM: We assessed the relationship between genital satisfaction, survey respondent sexual activity, and perceptions of anatomy and function. METHODS: A 54-item REDCap survey was distributed to any-gendered volunteers ≥18 years of age through ResearchMatch from January to March 2023. Responses were split into (1) high PGS and (2) low PGS. Analysis was performed using chi-square tests on survey responses and a Mann Whitney U test on median satisfaction level. OUTCOMES: Outcomes were genital anatomy perceptions, sexual activity, and respondents' PGS. RESULTS: Of the 649 respondents who started the survey, 560 (86.3%) completed it. Median PGS was 7 of 10, forming subgroups of high (≥7 of 10) satisfaction (n = 317 of 560 [56.6%]) and low (<7 of 10) satisfaction (n = 243 of 560 [43.4%]). The mean age was 45.8 ± 16.8 years, and demographics were notable for 72.1% women (n = 404 of 560), 83.2% White (n = 466 of 560), 47.9% married (n = 268 of 560), and 75.5% bachelor's degree holders (n = 423 of 560). Comparing high- and low-PGS groups, more low-PGS respondents felt normal flaccid penis length to be <2 inches (11.1% vs 5.1%; P = .008). High-PGS respondents more often responded that it is normal for women to have orgasms over half the time (20.8% vs 13.2%; P = .0002) or to identify as being sexually active (81.1% vs 71.6%; P = .008). Women were more likely than men to report larger normal testicle sizes as 60.1 to 90 mL (24.5% vs 10.3%; P < .0001), whereas more men felt that normal testicle size was 7 to 15 mL (26.3% vs 11.4%; P < .0001). Orgasm length perceptions also differed: more women felt female orgasm length was 2.6 to 5 seconds (36.6% vs 16.7%; P < .0001), and more men believed female orgasms to be longer, at 7.6 to 10 seconds (29.5% vs 17.3%; P = .002), 10.1 to 12.5 seconds (11.5% vs 5.2%; P = .0008), and >12.5 seconds (12.2% vs 5.7%; P = .009). Respondents' views on their genitalia differed by gender, with women more likely to feel that their genitals are normal compared with men (89.4% vs 75.0%; P < .0001). CLINICAL IMPLICATIONS: PGS may be a useful screening tool given its association with sexual activity. STRENGTHS AND LIMITATIONS: Our large-scale survey assesses public perceptions of genital anatomy and function. Limitations include a lack of gender nonbinary perceptions. CONCLUSION: Gender and PGS interact with perceptions of male anatomy and female sexual activity, and the frequency of sexual activity was higher among high-PGS respondents; however, the direction of these interactions remains unclear and requires future causal analysis.

The Utility of Sulfur Colloid Imaging to Differentiate Charcot's Neuroarthropathy from Osteomyelitis: A Case Study.

Charcot's neuroarthropathy and osteomyelitis can have similar initial presentations. The ability to differentiate between the two pathologic conditions is essential, as each requires different treatment. We present a case of a 53-year-old woman with pain, swelling, and warmth in her left first metatarsophalangeal joint and first tarsometatarsal joint. Radiographs showed comminuted fractures at the base of the first metatarsal. Osteomyelitis was suspected by the primary team based on physical findings and a history of previous first metatarsophalangeal joint arthrodesis. A triphasic bone scan and an indium white blood cell scan were positive for osteomyelitis. The podiatric medical team was suspicious for possible Charcot's neuroarthropathy based on physical findings and uncontrolled blood glucose levels at the time of her previous arthrodesis. A sulfur colloid scan was performed and compared with an indium scan, which showed no evidence of osteomyelitis. This case demonstrates the usefulness of sulfur colloid imaging compared with an indium white blood cell scan to differentiate osteomyelitis from Charcot's neuroarthropathy. This case also highlights the importance of using clinical judgment to make the correct diagnosis.

Critically Evaluating the Role for Postoperative Antibiotics in Patients Undergoing Urethroplasty With Buccal Mucosa Graft: A Claims Database Analysis.

OBJECTIVE: To compare outcomes among patients undergoing first-time urethroplasty with buccal mucosa graft (BMG) who receive postoperative antibiotics vs those who do not. METHODS: A retrospective cohort study was conducted using the TriNetX claims database between 2008-2022. Using CPT, ICD10, and LOINC codes, patients >18 years old undergoing primary urethroplasty with BMG who received an outpatient prescription for antibiotics between postoperative day 0-30 or did not were queried. Patients with positive preoperative urine culture or urinary tract infection (UTI) within 30days preoperatively were excluded. Surgical outcomes included 5-year revision rates and revision-free survival. Safety outcomes included new UTI within 30days, surgical site infection within 90days, or Clostridium difficile infection within 30days of urethroplasty. RESULTS: We identified 884 patients (81% antibiotic cohort, 19% nonantibiotic cohort) that met inclusion criteria. Age at time of urethroplasty, suprapubic tube presence, and pre-existing medical comorbidities were comparable between cohorts (Table 1A). There was no difference in 5-year rates and revision-free survival for endoscopic revision (11.5% vs 9.5%, relative risk (RR) 1.2, 95% CI [0.7, 2.0], recurrence-free survival (RFS) log-rank P = .6), re-do urethroplasty (12.9% vs 13.7%, RR 0.9, 95% CI [0.6, 1.5], RFS log-rank P = .7), or all-cause revision (19.8% vs 17.7%, RR 1.1, 95% CI [0.8, 1.6], P = .5) between groups. Postoperative rates of UTI, surgical site infection, and C difficile infection were similar between groups. CONCLUSION: In this large retrospective cohort study of patients undergoing urethroplasty with BMG, we observed no significant benefit from use of postoperative antibiotics on long-term revision rates or perioperative infectious complications.

Associations of Social Support With Physical and Mental Health Symptom Burden After COVID-19 Hospitalization Among Older Adults.

BACKGROUND: Despite significant support system disruptions during the coronavirus 2019 (COVID-19) pandemic, little is known about the relationship between social support and symptom burden among older adults following COVID-19 hospitalization. METHODS: From a prospective cohort of 341 community-living persons aged ≥60 years hospitalized with COVID-19 between June 2020 and June 2021 who underwent follow-up at 1, 3, and 6 months after discharge, we identified 311 participants with ≥1 follow-up assessment. Social support prehospitalization was ascertained using a 5-item version of the Medical Outcomes Study Social Support Survey (range, 5-25), with low social support defined as a score ≤15. At hospitalization and each follow-up assessment, 14 physical symptoms were assessed using a modified Edmonton Symptom Assessment System inclusive of COVID-19-relevant symptoms. Mental health symptoms were assessed using Patient Health Questionnaire-4. Longitudinal associations between social support and physical and mental health symptoms, respectively, were evaluated through multivariable regression. RESULTS: Participants' mean age was 71.3 years (standard deviation, 8.5), 52.4% were female, and 34.2% were of Black race or Hispanic ethnicity. 11.8% reported low social support. Over the 6-month follow-up period, low social support was independently associated with higher burden of physical symptoms (adjusted rate ratio [aRR], 1.26; 95% confidence interval [CI], 1.05-1.52), but not mental health symptoms (aRR, 1.14; 95% CI, 0.85-1.53). CONCLUSIONS: Low social support is associated with greater physical, but not mental health, symptom burden among older survivors of COVID-19 hospitalization. Our findings suggest a potential need for social support screening and interventions to improve post-COVID-19 symptom management in this vulnerable group.

Testing alternative hypotheses for the decline of cichlid fish in Lake Victoria using fish tooth time series from sediment cores.

Lake Victoria is well known for its high diversity of endemic fish species and provides livelihoods for millions of people. The lake garnered widespread attention during the twentieth century as major environmental and ecological changes modified the fish community with the extinction of approximately 40% of endemic cichlid species by the 1980s. Suggested causal factors include anthropogenic eutrophication, fishing, and introduced non-native species but their relative importance remains unresolved, partly because monitoring data started in the 1970s when changes were already underway. Here, for the first time, we reconstruct two time series, covering the last approximately 200 years, of fish assemblage using fish teeth preserved in lake sediments. Two sediment cores from the Mwanza Gulf of Lake Victoria, were subsampled continuously at an intra-decadal resolution, and teeth were identified to major taxa: Cyprinoidea, Haplochromini, Mochokidae and Oreochromini. None of the fossils could be confidently assigned to non-native Nile perch. Our data show significant decreases in haplochromine and oreochromine cichlid fish abundances that began long before the arrival of Nile perch. Cyprinoids, on the other hand, have generally been increasing. Our study is the first to reconstruct a time series of any fish assemblage in Lake Victoria extending deeper back in time than the past 50 years, helping shed light on the processes underlying Lake Victoria's biodiversity loss.

High-Intensity Care for Nursing Home Residents with Severe Dementia Hospitalized at the End of Life: A Mixed Methods Study.

OBJECTIVE: For nursing home residents with severe dementia, high-intensity medical treatment offers little possibility of benefit but has the potential to cause significant distress. Nevertheless, mechanical ventilation and intensive care unit (ICU) transfers have increased in this population. We sought to understand how and why such care is occurring. DESIGN: Mixed methods study, with retrospective collection of qualitative and quantitative data. SETTING: Department of Veterans Affairs (VA) hospitals. METHODS: Using the Minimum Data Set, we identified veterans aged ≥65 years who had severe dementia, lived in nursing homes, and died in 2013. We selected those who underwent mechanical ventilation or ICU transfer in the last 30 days of life. We restricted our sample to patients receiving care at VA hospitals because these hospitals share an electronic medical record, from which we collected structured information and constructed detailed narratives of how medical decisions were made. We used qualitative content analysis to identify distinct paths to high-intensity treatment in these narratives. RESULTS: Among 163 veterans, 41 (25.2%) underwent mechanical ventilation or ICU transfer. Their median age was 85 (IQR, 80-94), 97.6% were male, and 67.5% were non-Hispanic white. More than a quarter had living wills declining some or all treatment. There were 5 paths to high-intensity care. The most common (18 of 41 patients) involved families who struggled with decisions. Other patients (15 of 41) received high-intensity care reflexively, before discussion with a surrogate. Four patients had families who advocated repeatedly for aggressive treatment, against clinical recommendations. In 2 cases, information about the patient's preferences was erroneous or unavailable. In 2 cases, there was difficulty identifying a surrogate. CONCLUSIONS AND IMPLICATIONS: Our findings highlight the role of surrogates' difficulty with decision making and of health system-level factors in end-of-life ICU transfers and mechanical ventilation among nursing home residents with severe dementia.